Key messages

Bullying is a common factor in the life of many Australian children and young people. Bullying is physically harmful, socially isolating and psychologically damaging143

Young people with special needs, eg autism spectrum disorder (ASD) or other disability, are particularly at risk144

Recommendations

Health practitioners should ask young patients with chronic physical, social or mental health indicators about their experience of bullying143Level III-2 C

Health practitioners should understand that school programs can be very effective to deter and deal with bullying if supported across the whole school145Level I A

Introduction

Bullying can be broadly defined as: acts intended or perceived as intended to cause harm. It is unwanted, aggressive behaviour among children that involves a real or perceived power imbalance. The behaviour is often but not always repeated, or has the potential to be repeated, over time146–149

Cyberbullying interactions are enacted using electronic equipment, such as mobile phones or the internet, by one or more individuals towards another. Cyberbullying can take the form of instant or email messages, images, videos, calls and also the exclusion or prevention of someone being a part of a group or an online community.150

Sexting is the act of: creating, sharing, sending or posting of sexually explicit messages or images via the internet, mobile phones or other electronic devices by people, especially young people151,152

Intimate images taken with consent during a relationship may, when that relationship falters, be distributed to others for the purposes of humiliation and denigration of reputation, which raises moral, ethical, legal and parenting concerns. This is particularly worrisome because the behaviour occurs at a significant period in young people’s lives, just as they are developing their sexual identity and engaging in early romantic relationships.

It is important to understand that there may be legal implications and that there are laws in place that address the issue of sexting. As Butler et al have noted, ‘Schools should be aware of the potential for cyberbullying to amount to criminal behaviour, so they may better gauge when it may be appropriate to contact police.’153 For example, under the Criminal Code Act 1995 (Commonwealth) the misuse of telecommunications to menace, threaten or hoax other persons is potentially a criminal act.

Bullying can be characterised by its mode (for example – online, in person), type (verbal, relational), and the environment (school, home). The relationship context can be either explicit – sibling, dating partner, friend or acquaintance – or implicit, due to differences in popularity, economic status, academic status that may not be clearly apparent.154

It is worth noting that bullying behaviour doesn’t have to be repeated to have an impact; some isolated violent bullying situations can have a lasting impact. A further challenge is that there is usually an imbalance of power between the victim and the bully. On occasions, the power differential can be difficult to define or identify.146–149

Social norms also influence whether the behaviour is classified as bullying – for example, until fairly recently, many regarded sibling bullying as the normal ‘rough and tumble’ of growing up. This is despite the emerging evidence of both the extent and negative impact of sibling bullying which has been shown to compound school and other forms of bullying.155–157 Other social norms may make it difficult to distinguish between ‘healthy competition’ and physicality and bullying. In these situations, the repetition of such actions would tend to skew them towards bullying.

Prevalence

Bullying is a significant children’s health issue for GPs and the community. It has a high annual prevalence with up to 56% of young people involved either as victim, perpetrator or both.156,158–162 These figures may be underestimates as there is often a reluctance to disclose.163–165

The pattern of bullying varies, with verbal bullying occurring more frequently than physical or cyberbullying. Typically, there are repeated incidents over a period of time.

Cyberbullying is emerging as a significant new form as bullies move from ‘behind the scenes to behind the screens’. The recent emergence of the phenomenon of ‘sexting’, involving the sending and/or exchange of sexually explicit images by electronic means, is of concern to educators, healthcare providers, lawmakers and police.

The prevalence of cyberbullying and sexting has been hard to quantify given the variability in the definition. A national survey in 2010 revealed 59% of teenagers have sent sexually suggestive emails or messages.151A government study found 7–10% of Year 4 to 9 students reported they were bullied by means of technology over the school term.162

The probability of any one child being victimised is directly related to the number of risk factors she or he experiences.166 Children with special needs are particularly vulnerable to bullying with, in one study, over 60% of children diagnosed with ASD reporting they had been bullied.167,168

It is unclear whether the prevalence of bullying is higher in rural areas although the consequences may be worse due to:169

greater difficulties in accessing support services

issues surrounding confidentiality, especially if there is a mental health component

bullying and harassment potentially compounding other forms of discrimination.

The role of GPs

Prevention

GPs can be advocates in the school environment by voicing support for school anti-bullying programs and encouraging the parents of both bullies and victims to contact the school regarding support and additional counselling. GPs can also advocate through professional associations using policy, position statements, professional education or within local communities as opinion leaders and local champions.

The ability to cope with bullying is enhanced by involving caring adults, teaching appropriate cognitive and social skills and providing strong social support systems such as whole-of-school programs to deter and deal with bullying.

School programs can be very effective if supported across the whole school.145,170,171 Some have had good evidence of impact – for example, the KiVa school based anti - bullying program.173–175

Research is now identifying factors that may be associated with the increased likelihood that children will engage in bullying others. For example, parental anger with their children is associated with the increased likelihood of children engaging in bullying behaviour, while parental communication with their children and meeting their child’s friends is associated with a lower likelihood of children bullying others.166 In relation to young people who are victimised, recent research suggests that interventions are more likely to be successful if they focus on both the psychosocial skills of adolescents and their relationships with their family.173

Identification

Adverse health impact of bullying

There is a considerable burden of illness in both the short and long-term for both victims and bullies.155,176–182

The impact of cyberbullying on mental health and emotional response is only just beginning to be understood.183–185 It has been suggested that it will be significant due to the 24 hour nature of it, the anonymity aspects and the broader audience that can be targeted through the visual electronic media.

Bullying has a consistent, strong and graded association with a large number of physical and psychological symptoms.143,158,178,179,186–190 In the short-term, it is associated with:

Many people who bully are popular and have average or better-than-average self-esteem.199 They often take pride in their aggressive behaviour and control over the people they bully

People who bully may be part of a group that thinks bullying is okay. Some people who bully may also have poor social skills and experience anxiety or depression. For them, bullying can be a way to gain social status200 or power over others201

Nothing can be done at schools to reduce bullying

School initiatives to prevent and stop bullying have reduced bullying by 15–50%.145,170,171,175,202 The most successful initiatives involve the entire school community of teachers, staff, parents, students and community members

Kids grow out of it

For some (up to 50%), bullying continues as they become older.203 Unless someone intervenes, the bullying is likely to continue and, in some cases, grow into violence and other serious behavioural problems. Children who consistently bully others often continue their aggressive behaviour through adolescence and into adulthood178,196

While bully/victim numbers appear to decrease during adolescence; sibling bullying remains relatively stable over time, at least between 10 and 15 years of age 204

Parents always know when their child is being bullied

Adults (including teachers) often do not witness bullying despite their good intentions164,205

GPs can identify cases, or ‘case-find’ by thinking about whether bullying is occurring in typical presentations as outlined above.164,165,206–208

You have the opportunity to identify and support children who have been bullied through a careful history taking (refer to Box 5) followed up by counselling and support. It is important to listen and believe.

Box 5. Questions to consider

General

Many people experience bullying at school or via the net or phone or at home. Has this ever happened to you? How often? How long has this being going on for? What happens? How do you feel? Have you told anyone about it? Who can you go to for help if you are being bullied?

School

How is school going? What do you like about school? What are you good/not good at?

How many good friends do you have in school? How do you get along with others at the school and the teachers? Do you ever feel afraid to go to school?209

Up to 60% of victims of bullying have seen a GP in the last 12 months with a range of somatic or other symptoms. GPs should ask about bullying when children and adolescents present with unexplained psychosomatic and behaviour symptoms; when they experience problems at school or with friends; if they begin to use tobacco, alcohol, and other drugs; and if they express thoughts of self-harm or suicide.

Management

Support includes acknowledging that:165,207

they have shown courage in coming forward and talking about it and that they don’t have to face it on their own

it’s not their fault

all students have a right to learn in a safe environment

they should not tackle the bully by themselves

they should tell an adult or someone in authority.

GPs can be advocates for the child who is bullied.165,206–208,210 This can be done within the consultation by getting the family involved and encouraging them to take an active role in monitoring their children and engaging them in positive school and community activities.

Conclusion

In summary, the issue of school bullying in all its forms is now on the national and international research and policy agenda for all those concerned with the health, wellbeing and education of young people (refer to Caper).

As noted in this chapter, the matter of school bullying has been identified as a significant public health issue. GPs who are interested in treating the child and family unit as a whole are at the forefront in advocating for the wellbeing of young people. The following case study highlights the significant role of GPs in addressing and treating bullying.

Case study: Kristy

Kristy is 11 years old. She attends with her mother, Liz, holding out her arms and complaining of painful wrists that hurt when she moves them. The doctor does not know the family particularly well. Kristy has attended the practice intermittently for several years. It is only after the consultation that the doctor discovers that there has been a prior consultation where anxiety has been an issue. She is clearly perfectly well today – a bright young person who, while a little subdued, is easy to get on with. She allows the doctor to move her wrists passively through the full range of movements without wincing.

The doctor then asks about any stress in the background. Her mother discloses a torrent of troubles caused by the out-of-control behaviour of Kristy’s teenage brother Sam. The aggression, the opposition and the teasing of Kristy has escalated to an intolerable level.

The doctor has not seen Sam – a situation that appears likely to change.

In answer to a direct question, her mother says there has been recent bullying at school but that this has been attended to.

Given Kristy’s early adolescent stage of development and the ‘concrete thinking’ she displays that is typical of early adolescence, the doctor concludes this 10-minute consultation with some concrete declarations in conversation with Kristy.

Your body is very healthy (Kristy smiles).

The pain in your wrists is caused by the stress your brother is causing you and your family.

The brain makes stress chemicals that can cause pain.

our mum is going to look after you and your mum and I are going to have a meeting to plan how to get help.

Kristy and her mother leave with an apparent sense of purpose and relief. A further – and long – consultation is planned with Kristy’s mother alone. This consultation will brainstorm ways of improving family functioning and ways of minimising the impact of the current state of affairs on Kristy. The doctor needs to explore Kristy’s social and academic functioning and understand the nature of the bullying at school and at home, mentioned but not closely examined today. This will also involve planning an assessment of Sam’s issues with a view to intervention.

Skimming the notes afterwards the doctor discovers that she has seen Kristy a year earlier with weekday morning headaches but no school absence. Factors that emerged at the time included the mother’s own history of anxiety and the fact that Kristy had been excluded from socialising with a particular group of girls in the playground. It is also evident that Kristy had not been presenting recurrently with unexplained physical symptoms – a red flag for social or emotional distress. So that was promising.

Reflections

The risk of medicalising this presentation was avoided.

The consultation satisfies the important principle ‘to consider and address biomedical and psychosocial issues concurrently’.211

Fekkes M, Pijpers FI, Fredriks AM, et al. Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms. Pediatrics 2006;117:1568–74.